IV Hydration Therapy Enrollment Form

Client Name

First NameLast Name

Date of birth

Date

Phone Number

Country CodeArea CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Country CodeArea CodePhone Number

Please take a moment to answer the following questions

Are you presently taking any medications?

Please list

Are you pregnant?

Are you taking oral contraceptives?

Do you have any allergies to food or drugs?

Please specify

Please check if you are affected by or have any of the following

Please consent to the following:

Client Signature

Date

IV Hydration Scheduling